Are Patient Expectations and Illness Perception Associated with Patient-reported Outcomes from Surgical Decompression in de Quervain's Tenosynovitis?

BACKGROUND: Psychological factors such as depression, pain catastrophizing, kinesiophobia, pain anxiety, and more negative illness perceptions are associated with worse pain and function in patients at the start of treatment for de Quervain's tenosynovitis. Longitudinal studies have found symptoms of depression and pain catastrophizing at baseline were associated with worse pain after treatment. It is important to study patients opting for surgery for their condition because patients should choose surgical treatment based on their values rather than misconceptions. Psychological factors associated with worse patient-reported outcomes from surgery for de Quervain's tenosynovitis should be identified and addressed preoperatively so surgeons can correct any misunderstandings about the condition. QUESTION/PURPOSE: What preoperative psychosocial factors (depression, anxiety, pain catastrophizing, illness perception, and patient expectations) are associated with pain and function 3 months after surgical treatment of de Quervain's tenosynovitis after controlling for demographic characteristics? METHODS: This was a prospective cohort study of 164 patients who underwent surgery for de Quervain's tenosynovitis between September 2017 and October 2018 performed by 20 hand surgeons at 18 centers. Our database included 326 patients who underwent surgery for de Quervain's tenosynovitis during the study period. Of these, 62% (201 of 326) completed all baseline questionnaires and 50% (164 of 326) also completed patient-reported outcomes at 3 months postoperatively. We found no difference between those included and those not analyzed in terms of age, sex, duration of symptoms, smoking status, and workload. The mean ± SD age of the patients was 52 ± 14 years, 86% (141 of 164) were women, and the mean duration of symptoms was 13 ± 19 months. Patients completed the Patient-Rated Wrist Evaluation (PRWE), the VAS for pain and function, the Patient Health Questionnaire for symptoms of anxiety and depression, the Pain Catastrophizing Scale, the Credibility/Expectations Questionnaire, and the Brief Illness Perceptions questionnaire at baseline. Patients also completed the PRWE and VAS for pain and function at 3 months postoperatively. We used a hierarchical multivariable linear regression model to investigate the relative contribution of patient demographics and psychosocial factors to the pain and functional outcome at 3 months postoperatively. RESULTS: After adjusting for demographic characteristics, psychosocial factors, and baseline PRWE score, we found that only the patient's expectations of treatment and how long their illness would last were associated with the total PRWE score at 3 months postoperatively. More positive patient expectations of treatment were associated with better patient-reported pain and function at 3 months postoperatively (ß = -2.0; p < 0.01), while more negative patient perceptions of how long their condition would last were associated with worse patient-reported pain and function (timeline ß = 2.7; p < 0.01). The final model accounted for 31% of the variance in the patient-reported outcome at 3 months postoperatively. CONCLUSION: Patient expectations and illness perceptions are associated with patient-reported pain and functional outcomes after surgical decompression for de Quervain's tenosynovitis. Addressing misconceptions about de Quervain's tenosynovitis in terms of the consequences for patients and how long their symptoms will last should allow patients to make informed decisions about the treatment that best matches their values. Prospective studies are needed to investigate whether addressing patient expectations and illness perceptions, with decision aids for example, can improve patient-reported pain and function postoperatively in those patients who still choose surgery for de Quervain's tenosynovitis. LEVEL OF EVIDENCE: Level III, therapeutic study.

Depression and Pain Interference Correlate With Physical Function in Patients Recovering From Hand Surgery.

Background: Patient-reported outcome measures vary more than expected based on underlying pathology, in part due to the substantial influence of mood and coping strategies. Methods: This study addressed the primary null hypothesis that the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function score 1 month (range, 3-8 weeks) after hand surgery is not associated with PROMIS Depression and PROMIS Pain Interference scores prior to surgery, accounting for other factors. Using an institution-wide database of routinely collected patient-reported outcomes, we identified adult patients who underwent wrist ganglion excision, trapeziometacarpal arthroplasty, hand ganglion excision, trigger digit, De Quervain, and carpal tunnel release. Measures collected included the PROMIS Physical Function Computerized Adaptive Test (CAT), PROMIS Pain Interference CAT, and PROMIS Depression CAT. We sought factors associated with postsurgical PROMIS Physical Function scores and change between preoperative and postoperative score using multivariable linear regression, accounting for age, sex, surgery type, provider, and time from surgery to postsurgical measurement. Results: Higher postoperative PROMIS Physical Function score was independently associated with lower PROMIS Pain Interference scores, lower PROMIS Depression scores, younger age, and treatment by provider team 3. Greater change in PROMIS Physical Function score was independently associated with greater PROMIS Pain Interference scores, greater time from surgery, and treatment by provider team 3. Conclusions: Mood and effective coping strategies affect the level of symptoms and limitations during recovery from hand surgery and represent important treatment opportunities for enhancing recovery.

Psychologic Factors Do Not Affect Placebo Responses After Upper Extremity Injections: A Randomized Trial.

BACKGROUND: Studies on how psychologic factors influence the placebo effect have shown conflicting results in an experimental setting. Pessimists are more likely to experience a nocebo effect (feel worse after an inert intervention), whereas other studies suggest that patients with more symptoms of depression or anxiety or greater neuroticism have a greater response to a placebo. This is important because treatment benefits are potentiated by placebo effects, and optimal utilization of this phenomenon may improve clinical outcomes. QUESTIONS/PURPOSES: (1) What psychologic factors are associated with a decrease in magnitude of limitations (Disabilities of the Arm, Shoulder and Hand [DASH] score) and pain intensity (visual analog scale [VAS] for pain) after placebo injections for the treatment of painful nontraumatic upper extremity conditions? (2) What psychologic factors are associated with achieving a minimum clinically important difference (MCID) in disability and pain intensity? METHODS: We performed a secondary analysis of data acquired in two prospective, double-blind, randomized controlled trials of patients with lateral elbow pain, trapeziometacarpal arthrosis, and de Quervain tendinopathy who received a single injection of dexamethasone and lidocaine or lidocaine alone (placebo). One hundred six patients were included between June 2003 and February 2008. Sixty-three patients (59%) received dexamethasone and lidocaine, and we analyzed the subset of 43 patients (41%) who received lidocaine alone. The primary outcomes of interest were the DASH questionnaire and the VAS for pain measured three times: when they received the injection, between 1 and 3 months after the injection, and between 5 and 8 months after the injection. Seven patients missed the first followup visit and 14 patients missed the second visit. Based on previous research, we chose a MCID threshold of 10 for the DASH and a threshold of 1.0 for the VAS score. In bivariate analysis, we accounted for sex, race, marital status, degree, education, work status, pretreatment pain, diagnosis, symptoms of depression (Center of Epidemiologic Studies-Depression Scale), coping strategies in response to nociception (Pain Catastrophizing Scale), and personality traits (measured with the Multidimensional Health Locus of Control scale and the Eysenck Personality Questionnaire-Revised score). Variables with p values < 0.10 in bivariate analysis were included in the multivariable regression models. An a priori power analysis showed that a sample of 43 participants provides 80% statistical power, with α set at 0.05, for a regression with five predictors if the depression score would account for 15% or more of the variability in pain score. We used multiple imputations (imputations = 50) for a total of 66 (8.5%) missing or incomplete questionnaires. RESULTS: In the final multivariable models, no psychologic factors were associated with a change in DASH score between injection and followup, and no factors were associated with greater decrease in pain intensity. After injection, no psychologic factors were independently associated with achieving a MCID in the DASH and VAS. CONCLUSIONS: Our study confirms that patient factors are less important mediators of the placebo effect than clinician factors. In other words, clinician warmth and competence can help diminish symptoms and limitations of people in various states of mind, even when using inert or ineffective treatments. LEVEL OF EVIDENCE: Level II, therapeutic study.

Correlation of DASH and QuickDASH with measures of psychological distress.

PURPOSE: In an attempt to shorten the questionnaires given to patients in both clinical and research settings, we studied whether the correlation of commonly used psychological measures was comparable for the standard Disabilities of the Arm, Shoulder, and Hand (DASH) and the shorter QuickDASH questionnaires. METHODS: A cohort of 839 patients with carpal tunnel syndrome, trigger finger, de Quervain's disease, trapeziometacarpal arthrosis, lateral epicondylosis, or a distal radius fracture 2 weeks after surgery, who completed the DASH and 1 or more measures of psychological distress, was created from 10 databases from previously implemented studies. Correlations of the DASH and the QuickDASH with several measures of psychological factors (Center for Epidemiologic Studies Depression Scale [CES-D], Pain Catastrophizing Scale [PCS], and Pain Anxiety Symptoms Scale [PASS-40]) were calculated in both univariate and multivariable analyses. RESULTS: There was a large correlation between the DASH and QuickDASH (r = 0.79; p < .001). QuickDASH scores were significantly higher than DASH scores (p < .001). Correlations of the CES-D, PCS, and PASS-40 with the DASH and QuickDASH ranged from small to medium (range, 0.21-0.31; p < .001). There were no significant differences between correlations of the DASH and the QuickDASH with the psychological factors in the cohort including all patients, nor in subgroups according to diagnosis, gender, and limb dominance. CONCLUSIONS: The correlations of the DASH and QuickDASH with the CES-D, PCS, and PASS-40 were comparable. Our analysis suggests that a shorter and therefore potentially more practical measure of arm-specific disability can be used in studies that evaluate psychosocial aspects of illness behavior. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.